Nursing Elites

1. A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

• A. A client who has an open fracture of the femur
• B. A client who has periorbital ecchymosis
• C. A client who has asymmetrical thorax
• D. A client who has a deep-partial thickness burn on the lower extremities

Correct answer: C

Rationale: In a triage situation, an asymmetrical thorax suggests a potentially life-threatening condition such as a pneumothorax or hemothorax, requiring immediate attention. This client should be tagged as emergent. Periorbital ecchymosis and deep-partial thickness burns, while concerning, may not indicate an immediate life-threatening situation. An open fracture of the femur, although serious, can be prioritized after addressing emergent cases.

2. A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

• A. Measuring oxygen saturation for a client who has dyspnea
• B. Inserting a rectal suppository for a client who is vomiting
• C. Performing nasal hygiene for a client who has an NG tube
• D. Pouching a client's ostomy bag for a new colostomy

Correct answer: D

Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.

3. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

• A. Twitching
• B. Positive Trousseau's sign
• C. Hyperactive bowel sounds
• D. Hyperactive deep tendon reflexes

Correct answer: A

Rationale: The correct answer is A: Twitching. Hypocalcemia often presents with neuromuscular irritability, leading to manifestations such as twitching. Trousseau's sign is actually a positive indicator of hypocalcemia, not negative, making choice B incorrect. Hypoactive bowel sounds are not typically associated with hypocalcemia, making choice C incorrect. Similarly, hypoactive deep tendon reflexes are not a common finding in hypocalcemia, making choice D incorrect.

4. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• A. I can use another nurse's password as long as I log off after using the computer
• B. I should encrypt personal health information when sending emails
• C. I can post the client's vital signs in the client's room
• D. I should discard personal health information documents in the trash before leaving the unit

Correct answer: B

Rationale: The correct answer is B because encrypting personal health information when sending emails is a crucial aspect of maintaining client confidentiality. This process ensures that sensitive information is protected during electronic communication. Choice A is incorrect as sharing passwords violates client confidentiality. Choice C is incorrect as posting client's vital signs breaches confidentiality. Choice D is incorrect as discarding personal health information in the trash can lead to unauthorized access.

5. Diabetes insipidus is the result of:

• A. A diet high in sugar and carbohydrates.
• B. A complicated pregnancy.
• C. A disorder of the pancreas.
• D. A disorder of the pituitary gland.

Correct answer: D

Rationale: Diabetes insipidus is caused by a disorder of the pituitary gland affecting ADH regulation. This disorder results in the decreased production or release of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine properly. Choices A, B, and C are incorrect as they do not relate to the underlying cause of diabetes insipidus.

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